This Agency is an equal employment
opportunity employer. Federal law prohibits discrimination in
employment practices because of race, color, religion, sex,
age, national origin, citizenship status, disability, or
status as a Vietnam-era or special disabled veteran. No
question on this application is asked for the purpose of
limiting or excluding any applicant's consideration for
employment because of his or her race, color, religion, sex,
age, national origin, citizenship status, disability, or
status as a Vietnam-era or special disabled veteran.
Note: the term "I" and "me" that follows, applies to the
applicant.
I certify that all of the information given by me on this
application or in supplemental form is true and correct. I
further understand that false or misleading statements or
consequential omissions of any kind on this application or
supplemental forms are sufficient cause for my not being hired
or my dismissal if I am hired.
I agree, understand, and authorize that this Agency or its
agents may investigate my background to ascertain any and all
information of concern to my record, whether same is of record
or not. I authorize the persons or organization referenced in
this application to give the Agency any and all information
concerning my previous employment, education, or any other
information they might have, personal or otherwise, with
regard to any of the subjects covered by this application and
I release all such parties from all liability for any damage
that may result from furnishing such information to this
Agency.
I understand that employment with ACTS Home Health Care,
Inc. is conditional upon the successful completion of a drug
screening test. Successful completion of the test is no
guarantee of employment or job availability. I further
understand that I may be subject to periodic drug screening
during the course of my employment and that refusal to submit
to such screening will subject me to termination.
I understand that all offers of employment are made
conditional upon the satisfactory completion of a medical
examination by a doctor of the Agency's designation and the
satisfactory completion of the Agency Medical Questionnaire. I
understand that 'satisfactory completion' includes whether
reasonable accommodation is possible, and it also includes my
consent to the disclosure of any worker's compensation claims,
my medical records and exam results. It is agreed and
understood that this Application for Employment in no way
obligates the Agency to employ me and that any offer of
employment is subject to the terms and conditions stated on
this application form. I agree and understand that my
employment is for no definite duration and may be terminated
at will by either the Agency or me.
In the event of my employment, any Agency materials
entrusted me during the course of my employment will be
returned to the Agency on the last day of my employment,
whether I resign or be terminated. I agree and understand that
should I be employed, I will not at any time, directly or
indirectly, divulge, disclose or communicate to any person,
firm or corporation in any manner whatsoever any confidential
information concerning any matters affecting or relating to
the business of the Agency, including, but not limited to,
business information, strategic business plans, policies,
procedures, protocols, programs, projects, concepts, and other
proprietary information. I understand that I may be asked to
sign a confidentiality agreement consistent with this
paragraph as a condition of employment.
This certifies that this application was completed by me,
and that all entries on it and information in it are true and
complete.
